Abstract African American adults are less likely to receive analgesics, particularly opioids, even after controlling for pain severity. Research in the pediatric surgical population is more limited but the pattern of disparate use of opioids appears consistent with adult research. While it cannot be assumed that opioids are always the best approach to post-operative pain treatment for children, differential use driven by non-clinical judgments is concerning. Furthermore, adolescent access to prescribed opioids has increased, both through physician prescribing and misuse of medications prescribed to family members or friends. These concerns exist at a time when opioid addiction is a public health crisis. The relationship between racial disparities in postoperative pain management and opioid addiction is complex. Allowing a child?s pain to go unaddressed because of concerns driven by bias is unacceptable. On the other hand, overprescribing can enhance the risk for addiction or diversion of medications to the illicit market with broad societal implications. Striking the right balance requires empirical evidence that supports data-driven decision-making. This proposal aims to strengthen the evidence base regarding use of opioid pain medications in children following surgical procedures, and to explore the inter- related impacts of policy, clinical need, and socio-demographic factors by combining Medicaid claims and electronic health record data with findings from a statewide opioid policy inventory. This research will be done in Ohio, a state with the 5th highest opioid mortality rate in the nation, using clinical data from Nationwide Children?s Hospital (NCH), the nation?s largest pediatric surgical provider, performing over 35,000 pediatric surgical procedures each year across 10 pediatric surgical subspecialties and both in-patient and ambulatory surgery centers. We will focus on discharge prescribing of opioids in three high volume pediatric surgical procedures: tonsillectomy/adenoidectomy, supracondylar fracture, and appendectomy. Specifically, we aim to: 1) Determine the extent of and trends in racial disparities in postoperative discharge opioid prescribing since the 2011 onset of enhanced opioid prescription reduction activities; and 2) Develop an expanded model, including pain scores and other EMR data, to assess the linkage between differential opioid use for pediatric postoperative pain and opioid use-related outcomes. This proposed supplement extends the diagnoses, providers, and geographic regions addressed in the parent grant. Ultimately, this analysis will enhance our understanding of disparities in opioid use for pain management and support decision making for policy and practice that maximizes equity in pain management while remaining focused on reducing misuse and addiction.